How Embedding Care Standards Into the EHR

Empowers Clinical Variation Reduction

Session #3, February 12, 2019

John Kontor, MD | Scott Weingarten, MD, MPH

Optum

is a licensed reseller of Stanson Health, including its Choosing

Wisely

alert content evaluated in this study. Cedars-Sinai was the

major shareholder of Stanson Health, and Cedars-Sinai employed the

company’s founder Scott Weingarten, Cedars-Sinai, as Chief Clinical

Transformation Officer at the time of the study. Scott Weingarten has

served as CEO of Stanson.

Conflict of interest

Scott Weingarten, MD, MPH

Consultant to the CEO

Cedars-Sinai Health System

Professor of Medicine

Today’s presenters

JOHN KONTOR, MD

Practice Lead

Provider Technology Services

Optum

kontorj@advisory.com

SCOTT WEINGARTEN, MD, MPH

Consultant to CEO

Professor of Medicine

Cedars-Sinai Health System

CEO | Stanson

scott.weingarten@cshs.org

1. The opportunity: addressing unwarranted care variation

2. How Cedars-Sinai embedded guidance into workflows

3. Overview of Choosing Wisely

Clinical Decision Support

Adherence and Associated Inpatient Outcomes

4. What clinical decision support (CDS) empowered pathways

could mean for health care

Agenda

1. https://www.ajmc.com

• Recognize how Cedars-Sinai Health System implemented 18

high-volume alerts and measured their impact across 26,424

alerted inpatient encounters between October 2013 and July

2016

• Identify the association between adherence to multiple

evidence-based guidelines delivered via clinical decision

support and changes in clinical and financial outcomes

• Discuss implications of broader and more comprehensive

CDS adoption to address unwarranted care variation across

the patient journey

Learning objectives

The opportunity: Addressing

unwarranted care variation

Clinical standardization

Still a large, untapped opportunity

CFOs’ estimated

breakdown of cost

savings opportunities

N = 45

20%

25%

10%

40%

Clinical

standardization

Administrative

overhead

Capital

expenses

Labor costs

Supply

costs

Unwarranted

clinical variation

Differences in care that cannot be

explained by type or severity of illness

or patient preference

Root cause of:

• Preventable harm and poorer

outcomes due to inappropriate

or less effective care

• Avoidable cost due to fragmented

care processes and inefficient

resource use

1. Health Care Advisory Board meta-analysis of hospital and system CFOs, 2015.

Health systems can no longer afford to ignore unwarranted clinical variation

“Our mixed results highlight the need for interventions

beyond the current level of promotion, such as data feedback,

physician communication training, systems interventions

(e.g., clinical decision support in electronic medical records),

clinician scorecards, patient-focused strategies and financial

incentives.”

— Rosenburg et al., JAMA 2015

Agreement, education not sufficient

Source: Early Trends Among Seven Recommendations From the Choosing Wisely Campaign. Alan Rosenberg, MD; Abiy Agiro, PhD; Marc Gottlieb, MPA; John Barron, PharmD; Peter Brady, MBA; Ying Liu, MS; Cindy Li, MSc;

Andrea DeVries, PhD JAMA Intern Med. doi:10.1001/jamainternmed.2015.5441. Published online October 12, 2015.

Improve the value of care

Source: NEJM 2013;369:2551–7; Berwick DM, et al. JAMA. 2012;307:1513–6.

Technology value

10% of health care, or $158B–$226B,

estimated waste in U.S health care

due to overtreatment

80% to 90% of U.S. health care costs

are influenced by physician’s decisions

Patient care improvement 112 times

more effective when guidance is

in workflow

Physicians and hospitals seeking

ROI from EHRs

Automation value

Quality improvement and utilization management

Costs and productivity in health care

can be improved through technology

and automation

Information challenges

Medical research

funding

NIH research:

$37 billion in 2018

Global medical

research:

$140+ billion/year

Research output

• 20,000 biomedical journals

• 6,000 articles per day

• One article every 26 seconds

• 20,000 new lab tests

in the next 5 years

• Doubling time of medical

information 73 days in 2020

C L I N I C A L D E C I S I O N

S U P P O R T

The Choosing Wisely initiative

A provider-driven effort

The goal of Choosing Wisely is

to promote conversations between

clinicians and patients by helping

patients choose care that is:

• Supported by evidence

• Not duplicative of other tests

or procedures already received

• Free from harm

• Truly necessary

Choosing Wisely is an initiative of the

ABIM Foundation that seeks to advance a

national dialogue on avoiding unnecessary

medical tests, treatments and procedures.

Source: http://www.choosingwisely.org/

Obstacles to Choosing Wisely success

Ideally, an EHR infrastructure

could overcome these obstacles

and provide real-time computerized

clinical decision support to inform

health care providers when their

care deviates from evidence-

based guidelines.

Provider difficulty

interpreting guidelines and

evaluating patient risk

Patient need

for reassurance

Provider fear of

malpractice litigation

How Cedars-Sinai embedded

guidance into workflows

The new role of the academic medical center

Partners Healthcare, Massachusetts General, Brigham and Women’s Hospital. N Engl J Med. 369;11 NEJM.org 994 September 12, 2013.

“Charting our course under the current economic pressures won’t

be easy. But our AMCs have built their reputations by addressing

society’s most pressing health care challenges, and today’s

central challenge is the rising cost of health care. Fortunately,

AMCs specialize in innovation. We must now apply that capability

not just to scientific aspects of medical care but also to the

systems delivering it.”

How Cedars-Sinai implemented

clinical decision support

• More than 100 Choosing Wisely–based alerts

in production in the EMR

• Physician has the option to adhere, cancel,

change or justify

• Rates of adherence followed and can be linked

to outcomes

• Can we show an impact?

Choosing Wisely

Eliminate low performing alerts first —

reduce alert fatigue

Approximately alerts 250 per day

<2.5% of total alerts

Targeted alerts integrated

into physician workflow

Physician

starts order

in EHR

Likely

appropriate

Order

placed

Inappropriate order

cancelled

Likely

unnecessary

Logic

evaluates

30+

elements

Choosing Wisely:

Don’t perform population based screening for 25-OH-

Vitamin D deficiency.

(American Society for Clinical Pathology)

Hyperlink: Choosing Wisely – American Society for Clinical Pathology

Information for Patients: Vitamin D Tests (ASCP)

Reasons for override:

malabsorption

syndromes

meds (glucocorticoids,

antifungals, etc.)

diet excludes

dairy products

monitoring of known

vitamin D deficiency

dark skin complexion see comments

Comments:

remove order keep order

1. Note: CDS alert displays using EHR’s native best practice alerts; EHR’s do not allow use of actual screenshots.

Reducing alert fatigue

Reduce false positives

inclusion criterion

Vitamin D test ordered

exclusion criteria

males age > 70 years OR females age > 65 years

osteomalacia, vitamin D deficiency, osteoporosis,

pathologic fracture, chronic kidney disease, intestinal

malabsorption, cirrhosis, chronic liver failure, cystic

fibrosis, inflammatory bowel disease, radiation enteritis,

unspecified non-infections colitis, bariatric surgery,

hyperparathyroidism, chronic pancreatitis, COPD,

obesity/BMI >30, sarcoidosis, tuberculosis, histoplas-

mosis, coccidiomycosis, other fungal infections,

beryliosis, malignant lymphosarcomas, other

malignant lymphomas, diabetes, history of falls

Visit related to pregnancy

Active anti-seizure, antifungal, anti-retroviral

medications, glucocorticoids, or bile acid

sequestrants

IF Lab test order = LAB535

NOT (gender = female & age >= 70 years) OR (gender = male & age >= 65 years)

NOT ICD-9 OR ICD-10 diagnosis codes

268.0, 268.1, 268.2, 268.9, 733.00, 733.01, 733.02, 733.03, 733.09, 733.10, 733.11, 733.12, 733.13, 733.14, 733.15, 733.16, 733.19, 585.1, 585.2, 585.3, 585.4, 585.5, 585.6, 585.9, 579.0, 579.1, 579.2, 579.3, 579.4,

579.8, 579.9, 571.2, 571.5, 571.6, 572.2, 572.3, 572.4, 572.8, 573.0, 573.5, 277.00, 277.01, 277.02, 277.03, 277.09, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.1,

558.9, V45.86, 588.0, 588.81, 252.00, 252.01, 252.02, 252.08, 577.1, 491.0, 491.1, 491.20, 491.21, 491.22, 491.8, 491.9, 492.0, 492.8, 278.00, 278.01, 278.03, 135, 010.00, 010.01, 010.02, 010.03, 010.04, 010.05,

010.06, 010.10, 010.11, 010.12, 010.13, 010.14, 010.15, 010.16, 010.80, 010.81, 010.82, 010.83, 010.84, 010.85, 010.86, 010.90, 010.91, 010.92, 010.93, 010.94, 010.95, 010.96, 011.00, 011.01, 011.02, 011.03, 011.04,

011.05, 011.06, 011.10, 011.11, 011.12, 011.13, 011.14, 011.15, 011.16, 011.20, 011.21, 011.22, 011.23, 011.24, 011.25, 011.26, 011.30, 011.31, 011.32, 011.33, 011.34, 011.35, 011.36, 011.40, 011.41, 011.42, 011.43,

011.44, 011.45, 011.46, 011.50, 011.51, 011.52, 011.53, 011.54, 011.55, 011.56, 011.60, 011.61, 011.62, 011.63, 011.64, 011.65, 011.66, 011.70, 011.71, 011.72, 011.73, 011.74, 011.75, 011.76, 011.80, 011.81, 011.82,

011.83, 011.84, 011.85, 011.86, 011.90, 011.91, 011.92, 011.93, 011.94, 011.95, 011.96, 012.00, 012.01, 012.02, 012.03, 012.04, 012.05, 012.06, 012.10, 012.11, 012.12, 012.13, 012.14, 012.15, 012.16, 012.20, 012.21,

012.22, 012.23, 012.24, 012.25, 012.26, 012.30, 012.31, 012.32, 012.33, 012.34, 012.35, 012.36, 012.80, 012.81, 012.82, 012.83, 012.84, 012.85, 012.86, 013.00, 013.01, 013.02, 013.03, 013.04, 013.05, 013.06, 013.10,

013.11, 013.12, 013.13, 013.14, 013.15, 013.16, 013.20, 013.21, 013.22, 013.23, 013.24, 013.25, 013.26, 013.30, 013.31, 013.32, 013.33, 013.34, 013.35, 013.36, 013.40, 013.41, 013.42, 013.43, 013.44, 013.45, 013.46,

013.50, 013.51, 013.52, 013.53, 013.54, 013.55, 013.56, 013.60, 013.61, 013.62, 013.63, 013.64, 013.65, 013.66, 013.80, 013.81, 013.82, 013.83, 013.84, 013.85, 013.86, 013.90, 013.91, 013.92, 013.93, 013.94, 013.95,

013.96, 014.00, 014.01, 014.02, 014.03, 014.04, 014.05, 014.06, 014.80, 014.81, 014.82, 014.83, 014.84, 014.85, 014.86, 015.00, 015.01, 015.02, 015.03, 015.04, 015.05, 015.06, 015.10, 015.11, 015.12, 015.13, 015.14,

015.15, 015.16, 015.20, 015.21, 015.22, 015.23, 015.24, 015.25, 015.26, 015.50, 015.51, 015.52, 015.53, 015.54, 015.55, 015.56, 015.60, 015.61, 015.62, 015.63, 015.64, 015.65, 015.66, 015.70, 015.71, 015.72, 015.73,

015.74, 015.75, 015.76, 015.80, 015.81, 015.82, 015.83, 015.84, 015.85, 015.86, 015.90, 015.91, 015.92, 015.93, 015.94, 015.95, 015.96, 016.00, 016.01, 016.02, 016.03, 016.04, 016.05, 016.06, 016.10, 016.11, 016.12,

016.13, 016.14, 016.15, 016.16, 016.20, 016.21, 016.22, 016.23, 016.24, 016.25, 016.26, 016.30, 016.31, 016.32, 016.33, 016.34, 016.35, 016.36, 016.40, 016.41, 016.42, 016.43, 016.44, 016.45, 016.46, 016.50, 016.51,

016.52, 016.53, 016.54, 016.55, 016.56, 016.60, 016.61, 016.62, 016.63, 016.64, 016.65, 016.66, 016.70, 016.71, 016.72, 016.73, 016.74, 016.75, 016.76, 016.90, 016.91, 016.92, 016.93, 016.94, 016.95, 016.96, 017.00,

017.01, 017.02, 017.03, 017.04, 017.05, 017.06, 017.10, 017.11, 017.12, 017.13, 017.14, 017.15, 017.16, 017.20, 017.21, 017.22, 017.23, 017.24, 017.25, 017.26, 017.30, 017.31, 017.32, 017.33, 017.34, 017.35, 017.36,

017.40, 017.41, 017.42, 017.43, 017.44, 017.45, 017.46, 017.50, 017.51, 017.52, 017.53, 017.54, 017.55, 017.56, 017.60, 017.61, 017.62, 017.63, 017.64, 017.65, 017.66, 017.70, 017.71, 017.72, 017.73, 017.74, 017.75,

017.76, 017.80, 017.81, 017.82, 017.83, 017.84, 017.85, 017.86, 017.90, 017.91, 017.92, 017.93, 017.94, 017.95, 017.96, 018.00, 018.01, 018.02, 018.03, 018.04, 018.05, 018.06, 018.80, 018.81, 018.82, 018.83, 018.84,

018.85, 018.86, 018.90, 018.91, 018.92, 018.93, 018.94, 018.95, 018.96, 115.00, 115.01, 115.02, 115.03, 115.04, 115.05, 115.09, 115.10, 115.11, 115.12, 115.13, 115.14, 115.15, 115.19, 115.90, 115.91, 115.92, 115.93,

115.94, 115.95, 115.99, 117.0, 117.1, 117.2, 117.3, 117.4, 117.5, 117.6, 117.7, 117.8, 117.9, 007.2, 503, 200.00, 200.01, 200.02, 200.03, 200.04, 200.05, 200.06, 200.07, 200.08, 200.10, 200.11, 200.12, 200.13,

200.14, 200.15, 200.16, 200.17, 200.18, 200.20, 200.21, 200.22, 200.23, 200.24, 200.25, 200.26, 200.27, 200.28, 200.30, 200.31, 200.32, 200.33, 200.34, 200.35, 200.36, 200.37, 200.38, 200.40, 200.41, 200.42, 200.43,

200.44, 200.45, 200.46, 200.47, 200.48, 200.50, 200.51, 200.52, 200.53, 200.54, 200.55, 200.56, 200.57, 200.58, 200.60, 200.61, 200.62, 200.63, 200.64, 200.65, 200.66, 200.67, 200.68, 200.70, 200.71, 200.72, 200.73,

200.74, 200.75, 200.76, 200.77, 200.78, 200.80, 200.81, 200.82, 200.83, 200.84, 200.85, 200.86, 200.87, 200.88, 201.00, 201.01, 201.02, 201.03, 201.04, 201.05, 201.06, 201.07, 201.08, 201.10, 201.11, 201.12, 201.13,

201.14, 201.15, 201.16, 201.17, 201.18, 201.20, 201.21, 201.22, 201.23, 201.24, 201.25, 201.26, 201.27, 201.28, 201.40, 201.41, 201.42, 201.43, 201.44, 201.45, 201.46, 201.47, 201.48, 201.50, 201.51, 201.52, 201.53,

201.54, 201.55, 201.56, 201.57, 201.58, 201.60, 201.61, 201.62, 201.63, 201.64, 201.65, 201.66, 201.67, 201.68, 201.70, 201.71, 201.72, 201.73, 201.74, 201.75, 201.76, 201.77, 201.78, 201.90, 201.91, 201.92, 201.93,

201.94, 201.95, 201.96, 201.97, 201.98, 202.00, 202.01, 202.02, 202.03, 202.04, 202.05, 202.06, 202.07, 202.08, 202.10, 202.11, 202.12, 202.13, 202.14, 202.15, 202.16, 202.17, 202.18, 202.20, 202.21, 202.22, 202.23,

202.24, 202.25, 202.26, 202.27, 202.28, 202.30, 202.31, 202.32, 202.33, 202.34, 202.35, 202.36, 202.37, 202.38, 202.40, 202.41, 202.42, 202.43, 202.44, 202.45, 202.46, 202.47, 202.48, 202.50, 202.51, 202.52, 202.53,

202.54, 202.55, 202.56, 202.57, 202.58, 202.60, 202.61, 202.62, 202.63, 202.64, 202.65, 202.66, 202.67, 202.68, 202.70, 202.71, 202.72, 202.73, 202.74, 202.75, 202.76, 202.77, 202.78, 202.80, 202.81, 202.82, 202.83,

202.84, 202.85, 202.86, 202.87, 202.88, 202.90, 202.91, 202.92, 202.93, 202.94, 202.95, 202.96, 202.97, 202.98, 249.00, 249.01, 249.10, 249.11, 249.20, 249.21, 249.30, 249.31, 249.40, 249.41, 249.50, 249.51, 249.60,

249.61, 249.70, 249.71, 249.80, 249.81, 249.90, 249.91, 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42, 250.43,

250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 042, V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3,

V23.41, V23.42, V23.49, V23.5, V23.7, V23.81, V23.82, V23.83, V23.84, V23.85, V23.86, V23.87, V23.89, V23.9, V15.88, E885.9, E888.0, E888.1, E888.8, E888.9

NOT medication orders

10440, 10441, 10443, 10444, 10445, 10446, 10447, 10448, , 10011, 10012, 10013, 10879, , 10015, 10016, 10017, 10018, , 3910, , 11074

NOT BMI > 30 kg/m2

THEN fire Best Practice Advisory with 11 override reasons

CLINICAL LOGIC TRANSLATION

Choosing Wisely:

“Don’t perform population based screening for 25-OH-Vitamin D deficiency”

Measuring impact

If you trigger the same alert 10

times, do you order and cancel or

anticipate the alert?

If you have already explained the

test/procedure to the patient, do

you cancel or wait and not order

the next time?

Does not account for reduction

of inappropriate care

Cancelled orders

Inappropriate orders avoided

Adjusted ordering rates

Reduced rate

of inappropriate orders

Choosing Wisely alerts used during study

Antipsychotics for

insomnia in adults

Cardiac imaging for chest pain

patients at low risk

Lyme disease testing

Antipsychotics in

dementia patients

Carotid artery imaging

for simple syncope

NSAIDS in hypertension heart

failure or CKD patients

*

Appetite stimulants

in older adults

Chest X-ray at regular intervals



Repeat ultrasound for DVT

Benzodiazepines and sedatives

for patients older than 65



CT angio for pulmonary

embolism in young women

Routine 25-OH-Vitamin D

deficiency screening

Blood transfusion in patients

with Hgb greater than 7 g/dL

Erythropoiesis stimulating agents

Stress ulcer prophylaxis

medications for low-risk patients

*

Brain imaging for simple syncope

Imaging for pulmonary embolism

when pre-test risk is low

T3 levels in hypothyroid patients

Appropriate blood utilization

Physician

starts order

in EHR

Likely

appropriate

Order

placed

Inappropriate order

cancelled

Likely

unnecessary

Choosing Wisely:

Don’t transfuse more units of blood than absolutely

necessary.

(Society for Hospital Medicine)

1, 2, 3

Hyperlink: Choosing Wisely – Society of Hospital Medicine

Information for Patients: Blood Transfusion for Anemia in the Hospital

Reasons for override:

Active blood loss Hemoglobinopathy

Subarachnoid

hemorrhage

Chemotherapy

Comments:

remove order keep order

Don’t routinely transfuse stable, asymptomatic hospitalized patients with a hemoglobin level greater than

7–8 grams. Multiple factors need to be considered in transfusion decisions, including the patient’s clinical status and oxygen delivery

ability. Arbitrary hemoglobin or hematocrit thresholds should not be used as the only criterion for transfusions of packed red blood cells.

1.1

1.2

1.3

1.4

1.5

1.6

1.7

1.8

1.9

1000

2000

3000

4000

5000

6000

2012 2013 2014 2015

Case Mix Index

Crimson reported blood transfusions(

pRBC

units)

17% reduction

in blood utilization

while CMI increased

by 14%

* 2015 is projected from six months of data

** 2015 Case Mix Index (CMI) value is from January–June data

Sources of data

Study drew from three data sources

Data sent from the EHR to the CDS analytics platform

Data included the category of the provider triggering the alert (e.g., resident,

attending) and clinical data allowing for the assessment of adherence or non-

adherence to the alert during the encounter.

Claims data

Data included patient demographics (e.g., age, gender), diagnoses, services

provided, admit and discharge dates, Medicare Severity-Diagnosis Related

Group codes and costs.

Direct cost data associated with the patient care department.

Study population

26,424 encounters were included in the analysis

from of a total of approximately 100,000 encounters.

Adherent

encounters

Of the total encounters,

6% (1,591) of providers

adhered to all alerts.

Nonadherent

encounters

The remaining encounters

represent 94% (24,833) of

providers who did not adhere

to any alerts.

26,424

total encounters

94%

Clinical and financial outcomes

Patients whose physicians did not follow the Stanson Health

Choosing Wisely recommendations compared to those who did:

Odds of

complications

29%

Cost per

patient episode

6.2%

0.06 days

30-day

readmissions

14%

not statistically significant

Source: Median cost of encounter $12,940. Am J Manag Care. 2018;24(8):294-299.

Length of stay

7.3%

after adjusting for patient

illness severity and case

complexity

($944 per patient)

CDS approach

All CDS, whether alert, pathway, guideline, will:

• Be cloud-based

• Be more like Google

• Not require indications lists

• Have NLP, NLU, ML, AI capabilities

• Read and interpret free text

• Lower false-positive rates

• Measurable impact on quality and costs

Potential interventions

• Peer-comparison feedback

• Randomized controlled trial

• Low value care — antibiotics

for URIs:

– 248 providers

– 14,753 patient visits

Results

• Control:

24.1% to 13.1%

• Peer-comparison feedback:

19.9% to 3.7%, p<0.001

1 year later

• Drift

• Peer-comparison feedback

still has some impact

PAP smears

Percentage of potentially low-value care (n=47)

Physician 1

62%

Physician 2

Impact of CDS

Peer-comparison feedback

Order volume Alert firings

Cardiac imaging for screening low

-risk asymptomatic patients

AND annual stress testing after coronary revascularization

0.8%

↓

12.0%

↓

Creatine kinase

21.0%

↓

39.9%

↓

Lipoprotein (a)

54.5%

↓

49.0%

↓

Apolipoprotein B

57.2%

↓

58.9%

↓

Homocysteine

1.3%

↑

14.5%

↑

Lab bundle

25.4%

↓

42.0%

↓

Inappropriate vitamin-d screenings — BEFORE

January 2014

Inappropriate vitamin-d screenings — AFTER

May 2014

Order sets and preference lists

Standards for Inpatient

Electrocardiographic Monitoring

$3.7M

annualized savings

“hard green”

1. Identified cardiac monitoring/

telemetry in order sets and

preference lists

2. Utilized BPAs to guide practice

3. No change in mortality, rapid

response calls or code blues

TELEMETRY MONITORING

Source: Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association. Circulation. 2017;Oct 3:[Epub ahead of print].

O C T 0 4 , 2 0 1 7

Inappropriate care

Cedars-Sinai: Best 20th percentile (n=25 organizations)

Medical center results

Medical network results

Performance Year 3: 2015

• 12,989 patients

• Severity score 2.16 (average 1.28)

• Total saved $10,656,000

• 21% reduction in inpatient utilization

• 15% reduction in medications/1,000

• 6% reduction in imaging/1,000

• # 1 Anthem ACO for savings

Performance Year 4: 2016

(Preliminary 10/1/15–9/30/16)

• Total saved $2,200,000

ACO

Medical network results

ACO

Savings

IHA 2015 Commercial HMO Results

• 8.4% reduction in costs for CSMG

• 5.8% reduction in costs for CSHA

• 6th best out of 200 California physician

groups in cost reduction

• 15th best out of 200 California physician

groups in cost reduction

Expanded applications

of CDS-enabled care

Considering zone of innovation

BREADTH OF CDS APPLIED

CARE

DECISIONS

IMPACTED

Alerts Order sets

Dynamic forms,

displays

Expanded

orchestration

Single

decision

Multiple

decisions

Episodic care

pathways

Choosing Wisely

alerts

Prior

authorization

Potential impact of clinical decision support care adaptive pathways providing

patient-specific guidance across clinical decision support intervention types,

highlight use cases for:

Care pathways move beyond alerts and

rules to dynamically impact patient care

Vision: A patient-specific orchestration of evidence-based clinical decision support,

delivered in concert to a multidisciplinary care team across the patient episode.

Behind-the-scenes logic drives interventions

of all types, presented in EHR workflow

Care pathway is condition and patient-specific

Logic continuously tracks a patient’s progression

and adherence to its specific care plan

Analytics track adherence and pathway impact

Care pathway is easier to maintain and able to evolve

Behind the scenes algorithms dictate

available actions to the care team

Mark, 65-year-old male with heart

failure presents to emergency

department with acute exacerbation

Eligibility

check

Admitting physician

clicks “yes” to heart

failure pathway

Stage C

HFrEF

Stratification

and transfer

to IP

Management Post discharge

Decision

to admit

Discharge

Stage B

Management Post dischargeDischarge

Stage A

1. Relevant if not administered in ED.

2. Intended as example, doc templates to be

developed for multiple care team members.

Surveillance algorithm

(Dx Hx, lab results,

med Hx) alerts ED

physician of Mark’s

eligibility for HF care

Prompt

Enrollment

button

Nurse prompted to

administer diuretics

< 6 hrs

Rx alert

Includes Nurse

Navigator instructions

re: diet, meds, follow-

up, weight, etc.

Documentation

template

Auto-updates with

Hospitalist referral

to OP cardiac rehab

Task list

Reminds Nurse

Navigator to complete

follow-up call; clinical

visit summary sent

to PCP

Task list

Flags nurse that daily

weight has increased

Adverse

trend alert

Predicts discharge

disposition to “home”

Risk

calculator

Predicts readmission

risk and drives checklist

Risk

calculator

Nurse Navigator

documents follow-up

Doc

template

Order set

end alert

Smart form Smart form

Task list

IP attending orders

diagnostic, meds,

consult

Order set Task list

Pre-populates Mark

as smoker; triggers

cessation education

Prompts hospitalist

to order appropriate

discharge prescriptions

Rx alert

Portal

reminder

Patient reminder for

follow-up cardiology

appointment

Stage D

Post dischargeDischargeManagement

Enrollment

Care pathways are invisible to clinicians by guiding actions through expertly designed CDS

The next 100 years of medicine

“Complex but empirically validated algorithms will be embedded in

EHR systems as decision support tools to assist in everyday patient care.

Those management algorithms will evolve and be modified continuously

in accordance with inputs from ongoing clinical observations and from

new research. Clinical decision support algorithms will be derived entirely

from data, not expert opinion, market incentives, or committee consensus.”

December 27, 2012

Means to an end

Clinical Decision Support of the future

Mrs. Smith is a 64-year-old woman

with hypertension and diabetes.

Based upon her symptoms, genetic profile,

microbiome information, laboratory values,

personal preferences, vital signs, social

determinants …

After review of CDS …

Clinical Decision Support of the future

What is the optimal treatment

and monitoring of Mrs. Smith’s

hypertension and diabetes?

Opportunity

During the hour we spend together today:

Approximately 28 deaths in the U.S.

might occur because of medical errors

$22 million could be spent on medical over-treatment

Delivering value

“Of course it’s hard. It’s supposed to be

hard. If it were easy, everybody would

do it. Hard is what makes it great.”

Source: Wikipedia.com

Please remember to you complete our online session evaluation.

Thank you.

Thank you and questions

John Kontor, MD

Practice Lead

Provider Technology Services

Optum Advisory Services

kontorj@advisory.com

@johnkontor

Scott Weingarten, MD, MPH

Consultant to the CEO

Cedars-Sinai Health System

Professor of Medicine

scott.weingarten@cshs.org